Suture retention device

ABSTRACT

A tissue retractor for displacing body tissue during surgery includes a tissue piercing member such as a surgical needle, a wire-like filament such as a suture line affixed to the surgical needle, a fixed element such as an anchoring port being associated with a stable surgical platform such as a sternum retractor and a movable element such as an anchoring plug cooperating with anchoring port to engage a portion of suture line after the suture line is threaded through the body tissue with the surgical needle and after the suture wire is tensioned to effect a predetermined displacement of the body tissue. The predetermined displacement of body tissue is maintained by retention of the engaged portion of suture line by the fixed anchoring port and the movable anchoring plug.

This application is a continuation of application Ser. No. 11/689,768,filed Mar. 22, 2007 (pending) which is a continuation of applicationSer. No. 10/365,481, filed on Feb. 13, 2003 (abandoned) which is acontinuation of U.S. patent application Ser. No. 09/762,437, filed onApr. 10, 2001 (now U.S. Pat. No. 6,547,725) which is a U.S. NationalStage of International Application No. PCT/CA99/00740, filed on Aug. 10,1999 (expired), which claims the priority of Canadian Patent ApplicationNo. 2242295, filed Aug. 10, 1998, the disclosures of which areincorporated by reference herein.

FIELD OF THE INVENTION

The present invention relates to the field of surgical apparatus andmore specifically, to a suture and associated anchoring mechanism forapplying tissue retraction during surgery.

BACKGROUND OF THE INVENTION

Generally, surgery requires an incision through a patient's skin,underlying muscle and tissue to expose the underlying body organ oranatomical tissue which is in need of the particular surgicalintervention. In certain types of surgery such as cardiac surgery forinstance, the patient's bone structure may also be incised andretracted. This is the case with a midline sternotomy incision whichincises the patient's sternum and retracts the ribcage, or in situationswhere bone structure is spread apart without incision thereof as with anintercostal thoracotomy incision in which two adjacent patient ribs arespread apart in order to expose the underlying body organ, namely thepatient's heart.

To obtain and maintain a surgical window or opening onto the underlyingbody organ or tissue in relation to which the surgical intervention willtake place, abdominal or thoracic surgical retractors are usedsubsequent to the initial incision to spread the incised body tissue.Surgical retractors exist in many sizes and shapes and have been presentsince the dawn of surgery. Most known retractors have an elongate rackbar and two retracting arms, namely a fixed retracting arm and a movableretracting arm. Both arms typically extend in a direction normal to therack bar. The movable arm can be displaced along the rack bar, andrelative to the fixed arm, by using a crank to activate a pinionmechanism which engages teeth on the rack bar. Two blades are provided,usually disposed below the retractor arm and extending into the surgicalincision, to interface with the patient's skin and tissue and to applythe retraction that creates the surgical window by relative movement andan ensuing spacing apart of the two retractor arms. The retractor bladesmay also engage with the patient's bone structure during surgery thatrequires access to tissue or organs contained within the patient'sthorax. This is the case with coronary artery bypass graft (CABG)surgery, where the patient's skin and incised sternum are engaged withthe blades of a surgical retractor known as a sternum or sternalretractor. The basic surgical approach and surgical retractor design forcreating a surgical window onto the underlying tissue and organsrequiring the surgical intervention, whereby the two or more spreadermembers or retractor arms are moved apart to retract engaged tissue,have remained relatively unchanged since the first introduction ofretractors to surgery, regardless of the type, size and shape of thesurgical retractor. The surgeon may at times place a sterile drape,cloth, or other type of packing between the patient's incised bodytissue and the interfacing blades or other portion of the surgicalretractor.

Once the surgical window is created, the surgeon often times willretract other internal body tissue which becomes accessible through thesurgical window, with a flexible wire-like filament having atissue-piercing member on one end of the wire-like filament, such as asuture line with integral needle on one end of the suture line. Thesuture line with the integral tissue piercing needle at one end will bereferred to herein as the “traditional suture” or simply the “suture”.

A standard technique for retraction of coronary tissue during cardiacsurgery has been the use of sutures, including traction sutures and staysutures. These sutures are well known in the field of cardiac surgeryand are available in a variety of needle configurations, suture lengthand diameter thicknesses. The sutures are generally available in kitform in disposable sterilized packets containing a needle and a lengthof filament.

Internal body tissue may be retracted for a number of reasons duringsurgery, namely:

a) to improve access to the target body organ or target organ tissuerequiring the surgical intervention; this may be accomplished bydisplacing or retracting surrounding internal body tissue that mayobstruct, restrict or impede surgical access, as for instance whenretracting fatty tissue;

b) to maintain access to the inside of an organ cavity or body vesselsubsequent to an incision of the organ or vessel; this may beaccomplished by retracting incised portions of organ tissue or vesseltissue, as for instance when retracting incised portions of the aorta tomaintain access to the aortic valve;

c) to position or orient at least a portion of the body organ; this maybe accomplished through retraction of surrounding tissue which isanatomically attached to the body organ or through retraction of thebody organ directly.

Tissue retraction is typically achieved by piercing the body organ orbody tissue with a needle at the end of a suture line, threading alength of suture line through the pierced body tissue, and pullingsimultaneously on both resulting lengths of the suture line; that is,the length between the pierced tissue and the free end of the sutureline, and the length between the pierced tissue and the needle-bearingend of the suture line. Retraction loads are imposed on the body tissueor body organ at the location where the needle pierces and penetratesthrough the tissue or the organ.

In most surgical procedures, retraction is maintained by securing theabove mentioned two lengths of the suture line by accomplishing one ofthe following techniques:

a) tying the free end and needle-bearing end of the suture line to eachother through another part of the patient's anatomy, preferably remoteto the location of body tissue where the surgical intervention will takeplace;

b) simultaneously clamping these two lengths of suture line to otherbody tissue or to the sterile cloth or packing inserted between thesurgical retractor and the patient's incised tissue creating thesurgical window;

c) clamping these two lengths to the surgical retractor with a surgicalclamp or tying the free end and the needle-bearing end of these twolengths to each other and to a portion of the surgical retractor;

d) clamping these two lengths with a surgical clamp and wedging the tipor at least a portion of the surgical clamp between the retractor andthe patient's body or between the retractor and the sterile cloth orpacking placed along the surgical incision and trapped between theretractor blades and patient's body.

The current methods described above of maintaining tissue retractionmay, in some instances:

a) be time consuming, since securing of the retraction load through themanual tying of the suture line lengths is a multi-step threading andknotting procedure;

b) be cumbersome due to poor access during the manual tie down of thesuture line lengths, especially in surgical interventions when thesurgical window is small;

c) not be conducive to readjustment of the magnitude of the desiredtensile retraction load on the organ or body tissue, or on the directionof said load relative to the organ or body tissue without having tountie and retie suture line lengths or without having to cut theexisting suture line having the undesired retraction load and replacingit with a new suture that must again pierce the organ or body tissue andbe secured by way of one of the methods listed above;

d) compromise the ergonomics of and the surgeon's access into thesurgical window, especially when a surgical clamp is used to secure thetwo lengths of the suture line to the perimeter of the surgical windowor to a portion of the surgical retractor used to create the surgicalwindow, all the more when multiple suture lines need to be secured toachieve the desired organ or body tissue retraction;

e) hinder or restrict the readjustment of the surgical window openingthrough the opening or closing of the surgical retractor, if the lengthsof the suture line are tied to the rack bar of the surgical retractor,or hinder the deployment or readjustment of peripheral surgical devicesthat are mounted or need to be mounted on the spreader arms of theretractor.

Generally, adjustment of the desired tensile retraction by cutting anexisting suture line and repiercing a new suture line is not desirable.First, the process of placing a suture requires considerable manualdexterity, at times requiring the help of an assistant. The process istherefore tedious and time consuming. Second, a repiercing of theinternal body tissue or body organ with a subsequent suture tends toincrease the likelihood of inducing tissue trauma or tissue tearingwhich may have to be surgically repaired.

More recently with the advent of minimally invasive surgical techniques,laparoscopic approaches have been developed. Consequently, the surgicalaccess windows into the patient's abdomen or thorax have become smaller.However, internal tissue retraction through a suture (suture line with atissue piercing needle attached to at least one end) remains arequirement in certain types of surgical interventions. This tissueretraction with suture tends to generally be more difficult due to thesmaller access through a laparoscopic entry relative to the largersurgical access window obtained through the traditional retractedincision entry.

Although the principles of this invention may be applied to many typesof surgeries requiring tissue retraction by the application andmaintenance of a tensile load on a suture, the examples will focus oncardiac surgery; and more specifically, on CABG surgery performed on thebeating heart. In addition, although the examples will refer toretraction of internal body tissue, the concepts and principles may alsobe extended to external body tissue, as those skilled in this art willappreciate.

CABG surgery has been traditionally performed with the support of thecardio-pulmonary machine, whereby the patient's blood is oxygenatedoutside the body through extracorporeal circulation (ECC). This allowsthe surgeon to manipulate and operate on a perfectly still heart. Duringtraditional CABG surgery, the surgeon or assistant can manually positionand orient the arrested heart for best access to the target arteryrequiring the bypass graft.

Recently, in an aim to render CABG surgery less invasive to the patient,beating heart CABG surgery is being developed whereby ECC, one of themost invasive aspects of cardiac surgery, is eliminated and coronaryartery revascularization is performed directly on the beating heart. Oneof the challenges in performing beating heart CABG surgery lies inpositioning and orienting the beating heart in order to obtain access tothe inferior and posterior artery beds, while tending to minimizephysiologically undesirable effects such as hemodynamic instability,arrhythmia, or a precipitous drop in arterial pressure, that may occuras a result of such manipulations. In traditional CABG surgery the heartis arrested and therefore heart manipulations are well tolerated.

During CABG surgery or beating heart CABG surgery, the pericardium,namely the membranous sac in which the heart and the commencement of themajor blood vessels connecting with the heart are contained, isgenerally incised and unraveled to expose at least a portion of theheart surface which is to receive the bypass graft. The pericardiumtissue, unlike the heart, is not beating and can be separated from theheart surface except in some locations where it is anatomically attachedto the heart. Thus, it is surgically possible to position or orient theheart by manipulating the pericardium tissue to which it is attached. Inbeating heart CABG surgery, it may be desirable to position and orientthe beating heart through retraction of the pericardium tissue to obtainaccess to the inferior and posterior coronary artery beds. Thelikelihood of inducing trauma to the beating heart tends to be reduced,and the physiologically undesirable effects mentioned above tend to bereduced, since direct contact with the beating heart is avoided and themanipulations are achieved through retraction of the pericardium tissuewhich, although incised remains anatomically attached to the beatingheart in certain locations.

Based on the foregoing, it would therefore be advantageous to provide asuture with an integral anchoring member that may be inserted into ananchoring port of a stable platform (such as a surgical retractor) totend to achieve and maintain the desired tissue retraction load on theorgan or body tissue of the patient in a relatively quicker and moreconvenient fashion than some of the prior art methods described above.

Alternatively, based on the foregoing, it would also be advantageous toprovide a surgical retractor configured with an integral sutureanchoring mechanism or add-on suture anchoring mechanism capable ofengaging a traditional suture (namely, as explained above, a suturecomprised of a suture line with tissue piercing needle attached to atleast one end) to tend to achieve and maintain the desired tissueretraction load on the organ or body tissue of the patient in arelatively quicker and more convenient fashion than some of the currentmethods described above.

Thus it is one of the objects of the present invention to aim to reducedeployment times associated to the placement of tissue retractionsutures and to facilitate the securement thereof during surgery.

It is another object of the present invention to provide a tissueretractor comprising a suture line allowing the retraction of bodytissue or body organs during the surgical intervention that aims toeliminate the operation of manually tying suture line lengths to oneanother through a multi-step threading and knotting procedure in orderto achieve the said retraction.

It is another object of the present invention to provide a tissueretractor comprising a suture line allowing the retraction of internalbody tissue or body organs during the surgical intervention whichpermits the readjustment of the retraction force applied by said sutureline to the internal body tissue, either in magnitude or in direction,without requiring the severing or disposal of said suture line andwithout the removal of said suture line from internal body tissue.

These and other objects of the present invention will become apparentfrom the description of the present invention and its preferredembodiments which follows.

SUMMARY OF THE INVENTION

According to one broad aspect of the present invention, there isprovided a tissue retractor for displacing body tissue during surgery,the tissue retractor comprising a surgical tissue piercing member; asuture line affixed to the surgical tissue piercing member; a fixedelement, the fixed element being associated with a stable surgicalplatform; a movable element, the movable element cooperating with thefixed element to engage a portion of the suture line after the sutureline is threaded through the body tissue with the surgical tissuepiercing member and after the threaded suture line is tensioned toeffect a predetermined displacement of said body tissue; and whereinsaid predetermined displacement of said body tissue is maintained byretention of the engaged portion of the suture line by the movableelement and the fixed element.

In some surgical interventions, the foregoing features contribute toattempt to position and orient the beating heart through retraction ofthe incised pericardium tissue during beating heart CABG, while tendingto minimize the likelihood of inducing physiologically adverse effectssuch as hemodynamic instability, arrhythmia, or a precipitous drop inarterial pressure.

BRIEF DESCRIPTION OF THE DRAWINGS

For better understanding of the present invention and to show moreclearly how it may be carried into effect, reference will now be made byway of illustration and not of limitation to the accompanying drawings,which show an apparatus according to preferred embodiments of thepresent invention, and in which:

FIG. 1A is a perspective view illustrating a tissue retractor comprisinga suture and associated anchoring mechanism according to a firstembodiment of the present invention;

FIG. 1B is an exploded view of the suture and anchoring mechanismillustrated in FIG. 1A;

FIG. 1C is a partially assembled view of the suture and anchoringmechanism illustrated in FIG. 1B depicting a partially anchored sutureline;

FIG. 1D illustrates a variant of the disposition of the suture line withreference to the first embodiment of FIGS. 1A to 1C;

FIGS. 2A to 2C illustrate several variants of anchoring members of theanchoring mechanism with reference to the first embodiment of FIGS. 1Ato 1D;

FIGS. 3A to 3C illustrate several variants of an anchoring member of theanchoring mechanism of the first embodiment of FIGS. 1A to 1D comprisingan anchoring member handle;

FIGS. 4A and 4B illustrate variants of anchoring members of theanchoring mechanism with reference to the first embodiment of FIGS. 1Ato 1D, comprising openings therein suitable for reception of a sutureline;

FIGS. 5A and 5B illustrate a tissue retractor comprising a suture andassociated anchoring mechanism according to a second embodiment of thepresent invention;

FIGS. 5C and 5D illustrate several variants of anchoring members of theanchoring mechanism with reference to the second embodiment of FIGS. 5Aand 5B;

FIG. 6A is a perspective view illustrating a tissue retractor comprisinga suture and associated anchoring mechanism according to a thirdembodiment of the present invention;

FIG. 6B is an exploded view of the anchoring mechanism according to thethird embodiment of the present invention illustrated in FIG. 6Acomprising a pinch roller member and traction roller member;

FIG. 7A is a perspective view of a tissue retractor comprising a sutureand associated anchoring mechanism according to a fourth embodiment ofthe present invention;

FIG. 7B is a top view of the tissue suture and associated anchoringmechanism of FIG. 7A comprising a pawl-shaped lever member;

FIG. 8A is a perspective view of a tissue retractor comprising a sutureand associated anchoring mechanism according to a fifth embodiment ofthe present invention;

FIG. 8B is a side elevational view of the suture and associatedanchoring mechanism of FIG. 8A comprising a screw member andspring-loaded washer member;

FIG. 9A is a perspective view of a tissue retractor comprising a sutureand associated anchoring mechanism according to a sixth embodiment ofthe present invention;

FIG. 9B is a side elevational view of the suture and associatedanchoring mechanism of FIG. 9A comprising a swing plate lever member.

DETAILED DESCRIPTION OF THE ILLUSTRATIVE EMBODIMENTS

The features and principles of this invention can be applied, in wholeor in part, to many types of surgical procedures including those whichrely on surgical retractors to create and maintain a surgical windowinto the patient's incised skin for access into the patient's abdomen orthorax, and those which rely on laparoscopic entry ports into thepatient's skin to gain such access. The description of the preferredembodiments will be illustrated with respect to sternum retractors usedin cardiac surgery, for instance those used to perform traditional CABGsurgery with ECC, beating heart CABG without ECC, or valve surgerythrough a midline sternotomy incision. However, some of the features andprinciples may also apply to other types of retractors, such asabdominal retractors and thoracic retractors used in other types ofsurgical procedures. Some of the features and principles may even applyto other substantially stable surgical platforms which can be configuredwith an anchoring port or anchoring mechanism as described andillustrated in the embodiments herein. Such surgical platforms wouldinclude: a surgical table, a surgical bridge or truss member attached toa surgical table and spanning the patient or set adjacent the patient; asurgical attachment for fixturing an instrument used in laparoscopicsurgery to a surgical table, surgical bridge or truss, or a surgicalinstrument as may be used in laparoscopic surgery, or other likeplatforms.

In part, the embodiments of this invention may advantageously beapplied, if desired, to the retractor described in copending Canadianpatent application Serial No. 2,216,893 filed on Sep. 30, 1997 in thenames of Cartier and Paolitto and entitled “Sternum Retractor forPerforming Bypass Surgery on the Beating Heart”, and in copendingCanadian patent application Serial No. 2,232,795 filed on May 22, 1998in the names of Paolitto et al. and entitled “Manipulation andAdjustment of Surgical Instruments”, the contents of each of which areincorporated herein by reference. These existing applications have beenassigned to CoroNéo Inc., the assignee of the present application.

By way of a general overview and with reference to FIG. 1A, a surgicalapparatus with which the invention may be used is comprised of two maincomponents, a tissue retractor 2 and a sternum retractor 1. The sternumretractor 1 is provided with a plurality of anchoring ports 90 toreceive at least one said tissue retractor 2 in at least one saidanchoring port 90, in order to effectuate the desired tissue retractionof internal body tissue (labeled IBT). The tissue retractor 2 isillustrated after having pierced internal body tissue IBT, prior to itsintended engagement with the sternum retractor 1 and more specificallywith one of the anchoring ports 90 thereof. The sternum retractor 1 isillustrated in its deployed state, thereby creating and maintaining thesurgical window (labeled SW) that provides the surgeon with access tothe patient's internal coronary organs, which include the heart, thepericardium tissue, the aorta and vena cava, the coronary arteries andveins, the pleurae, the thymus, and other anatomical features, all ofwhich are collectively and schematically depicted as internal bodytissue IBT.

The sternum retractor 1 includes four major parts: (i) an elongated rackbar 5, (ii) a first retractor spreader arm 3 being preferably fixed tothe rack bar 5, (iii) a second retractor spreader arm 4 being preferablymovable with respect to the rack bar 5, and (iv) an actuator 6 foreffecting movement of the retractor spreader arm 4 relative to retractorspreader arm 3.

Retractor spreader arms 3 and 4 extend in a direction substantiallytransversely with regard to the rack bar 5, generally in the samedirection therefrom and in a parallel orientation with respect to oneanother. The movable arm 4 can be displaced along the rack bar 5, andrelative to the other arm 3, preferably through the rotation of theactuator 6 activated by the surgeon. The actuator 6 is operativelyconnected to the rack bar 5 and to the other spreader arm 4, and istranslatable along the length of the rack bar 5. This is preferablyachieved by the engagement of a pinion mechanism (not shown) of actuator6 with the rack teeth 52 on rack bar 5. Two retractor blades 7 (notwholly visible in FIG. 1A) and 8 are respectively provided with theretractor spreader arms 3 and 4, preferably disposed below the rack bar5 when the sternum retractor 1 is deployed on a patient. The retractorblades 7 and 8 engage with and serve to retract a portion of thepatient's incised skin, the two halves of the patient's incised sternumand the patient's ribcage thereby exposing the coronary organs to beoperated on through the resultant surgical window (labeled SW). The leftand right sides of the retracted surgical incision (labeled LSI and RSIrespectively) are schematically illustrated in FIG. 1A. When viewing theresultant surgical window SW from above the patient, the retractor arms3 and 4 of the deployed surgical retractor 1 each have a generallyarcuate orientation.

The sternum retractor 1 advantageously comprises arcuate rails 70 and 80along the top of arcuate retractor spreader arms 3 and 4, respectively.The rails 70 and 80 configure an inverted T-slot arcuate passage 71 and81, respectively, preferably centrally located within said rails, andpreferably extending throughout the entire arcuate length of said rails.A similar linear longitudinal rail 50, may also be configured along thetop of rack bar 5. Longitudinal rail 50 is also configured with aninverted T-slot longitudinal passage 51, preferably extending throughoutits entire longitudinal length. These said rails form a mountingperimeter that can advantageously serve to engage a positioning andarticulation mechanism utilized to place a variety of heart stabilizersduring beating heart bypass surgery, for instance, as described inpreviously mentioned Canadian application Serial No. 2,216,893.Alternatively, the positioning and articulation mechanism may also beutilized to set a coronary organ contacting member used in cardiacsurgery, such as a valve tissue retractor for example. As well, theserails can also be utilized to engage other surgical apparatus, that mayneed to be secured along the perimeter of the sternum retractor 1 duringcardiac surgery.

A plurality of slit-like channels 72 and 82 are configured along thearcuate arms 3 and 4 and cut through the arcuate rails 70 and 80,respectively. FIG. 1A illustrates three such slit-like channels 72 onthe retractor spreader arm 3 and three such slit-like channels 82 on theretractor spreader arm 4. The slit-like channels 72 and 82 extenddownwards from the top of the rails 70 and 80 to a depth preferablybelow the entire depth of the inverted T-slot arcuate passages 71 and81, preferably by an amount equivalent to the width of said slit-likechannel. Similar slit-like channels were introduced in above mentionedCanadian patent application Serial No. 2,232,795, in order to providepassages for the placement of sutures serving to retract body tissue,for example pericardium tissue. The slit-like channels in the presentinvention and in Canadian application 2,232,795 are configured so that asuture line or other like wire-like filament will not restrict orotherwise hinder the functionality of the positioning and articulationmechanism when such mechanism becomes engaged in said passages 71 and 81of said rails 70 and 80, provided the suture line or other wire-likefilament is placed in the deepest position within said slit-likechannel.

The sternum retractor 1 is configured with a plurality of anchoringports 90, preferably disposed laterally outward away from the perimeterdelineated by retractor arms 3 and 4, and consequently laterally outwardaway from the surgical window SW, in order to aim to maximize the accessand visibility into the SW. For instance, the plurality of anchoringports 90 can be configured laterally inward from the retractor arms 3and 4, or configured as material extensions to retractor blades 7 and 8,but this would tend to compromise the ergonomics of the surgeon'sworkspace and access into the surgical window SW even though theslit-like channels 72 and 82 may be eliminated in this alternateconfiguration. It is also preferable to have each anchoring port 90 inline with each of slit-like channel 72 or 82, so that said anchoringport can conveniently serve to secure the tissue retractor 2 when atleast a portion of the said tissue retractor is engaged in saidslit-like channel.

The tissue retractor 2 is comprised of several main parts: (i) atissue-piercing member such as a curved needle 20, (ii) a wire-likefilament such as a suture line 23, (iii) an anchoring member such asanchoring plug 25, and (iv) an anchoring port 90. The curved needle isof a substantially circular cross-section having a sharp tip 201suitable for piercing and penetrating body tissue, and a substantiallyblunt end 202 which is preferably integrally attached to the suture line23 at point A. The material of both the suture line 23 and the curvedneedle 20 are as per existing suture lines and needles customarily usedin surgery. The surgeon typically manipulates the needle 20 by graspingsaid needle between the jaws of a surgical needle holder, surgicalclamp, or other surgical implement routinely used in surgery formanipulating the needle portion of traditional sutures. The anchoringplug 25 is also preferably integrally attached to the other end ofsuture line 23 at point F. Depending on the size of the surgical windowSW required for the surgical intervention, the suture line 23 is of asuitable overall length, for instance between point A and F thereof, topermit retraction of the desired internal body tissue IBT by securingthe tissue retractor 2 to the sternum retractor 1, in a manner that willbe described in more detail below. The anchoring plug 25 furtherpreferably incorporates a suture-locating slot 251 at its free end,whose function will be described in greater detail below. Thelongitudinal axis of the suture-locating slot 251 is preferablyperpendicular to the longitudinal centerline axis of the anchoring plug25.

In this first embodiment, as further illustrated in FIGS. 1B-1D, theanchoring port 90 is illustrated as being integral with the retractorarms 3, such as a cast boss, a brazed-on boss or a welded-on boss.Alternatively, the anchoring port 90 may also be a separate componentthat is mechanically fastened to the retractor arm 3 (or 4) by a varietyof conventional fastening methods, such as bolting or riveting, in amanner that renders it fixed relative to the sternum retractor arm 3 (or4) on which it is assembled, at least for the duration of the surgicalintervention for which tissue retraction is performed. The anchoringport 90 in this embodiment is a substantially cantilevered fitting 901,disposed laterally outwards from the arcuate curvature of retractor arm3 or 4, its top face 904 preferably having a substantially horizontalorientation when sternum retractor 1 is deployed in the patient. Anaperture 902, preferably a through hole, is configured in the center offitting 901, with the longitudinal axis of said aperture beingpreferably substantially vertical and substantially perpendicular to thelaterally disposed, horizontally oriented fitting 901. Relative to thearcuate rail 70 (or 80), the top face 904 of the fitting 901 is situatedbelow the maximum depth of slit-like channel 72.

The geometry of the aperture 902 can take on many variants (cylindricalaperture, conical aperture, tapered aperture, hexagonal cross sectionaperture, elliptical cross section aperture, and other geometries thatwill be apparent to those skilled in the art) but in all cases willdepend on the geometry of the cooperating anchoring plug 25 which mustremain secure relative to the anchoring port 90, and retractor arm 3 (or4) on which said anchoring port is disposed, after the engagement of theanchoring plug 25 into the said port 90. A chamfer-like feature 903 isalso preferably configured on the top surface 904 of fitting 901, aroundthe perimeter of aperture 902, to ease the entry of anchoring plug 25into aperture 902. In this embodiment, the anchoring plug 25 is definedby a substantially conical surface 252, truncated at its narrower freeend by the surface defining the suture-locating slot 251. Preferably,the cross section of aperture 902 is progressively smaller in area, fromits maximum area at the top surface 904 to a smaller area at its maximumdepth in fitting 901, in order to promote wedging with the plug outersurface 252 when anchoring plug 25 is inserted and engaged into saidaperture. The maximum diameter of the anchoring plug 25 is at least aslarge as the minimum diameter of aperture 902 so as to result in asubstantially tight fit when said plug is engaged in said aperture. Themaximum diameter of the anchoring plug 25 is preferably only slightlylarger than the maximum diameter of the aperture 902, such that whensaid plug is fully engaged in said aperture, its top face 253 is locatedonly slightly proud from fitting top face 904, with the result that thesuture line 23 which is in tension from the retraction load it appliesto the internal body tissue IBT is resting at the maximum depth withinslit-like channel 72 in order not to interfere with the above mentionedpositioning and articulation mechanism, or other surgical apparatus,which may be engaged or moved through the arcuate passage 71 (or 81).

FIG. 1C illustrates a partially engaged anchoring plug 25 withinaperture 902. When the anchoring plug 25 will be fully engaged inaperture 902, the top face 253 will be substantially coincident with topface 904, thereby downwardly situating the length of suture line 23between points F and D thereof such that the length of suture line 23passing through the slit-like channel 72 will also come to rest at themaximum depth of said slit-like channel. This tends to ensure that thetissue retractor 2, and more specifically its suture line 23, ismaintained in close proximity to the sternum retractor surfaces therebyaiding to improve the ergonomics of the surgical work site. When theanchoring plug 25 is fully engaged within aperture 902, the narrowerfree end of the anchoring plug and suture locating slot 251 extend belowthe fitting 901. Disengagement of the anchoring plug 25 from theanchoring port 90 is achieved by pressing upward on the suture locatingslot 251, in a direction substantially parallel to the longitudinal axisof the aperture 902. The concavity of the suture locating slot 251provides a groove for the surgeon's finger thereby tending to improveadherence while the disengagement load is applied. This said concavitymay also be advantageously engaged with a surgical clamp, needle holder,or other surgical implement which may be used to apply the disengagementload.

In all the descriptions of embodiments according to the presentinvention, it is assumed that once the desired tissue retraction load isapplied to the internal body tissue IBT, the tissue-piercing point ofentry into the internal body tissue IBT (substantially coincident withpoint D on FIG. 1A and tissue-piercing point of exit out of internalbody tissue IBT (substantially coincident with point C on FIG. 1A aresituated below the plane formed across the top of arcuate rails 70 and80 of a deployed sternum retractor 1 by at least the depth of theslit-like channels 72 and 82.

For purposes of illustrating the principles of the present invention,points A to F have been defined along the length of suture line 23.Point A is the extremity of suture line 23 attached to curved needle201. Point F is the opposite extremity of suture line 23 attached toanchoring plug 25 or in some embodiments of the invention is the freeend of suture line 23. Point C is the point along the length of sutureline 23 located at the interface with internal body tissue IBT where theneedle 20 exited therefrom during deployment of tissue retractor 2.Point D is the point along the length of suture line 23 located at theinterface with internal body tissue IBT where the needle 20 pierced andentered into said internal body tissue IBT during deployment of tissueretractor 2. Point B is a point along the length of suture line 23between point A and C to be selected for engagement with anchoring plug25, or in later embodiments with a portion of other anchoringmechanisms. Point E is a point along the length of suture line 23between point D and F to be selected for engagement with anchoring plug25, or in later embodiments with a portion of other anchoringmechanisms. The relation of each points B, C, D, or E relative to eachof points A or F is variable and arbitrary, depending in part on: thelength of suture line 23 that is threaded through the internal bodytissue IBT in a specific deployment of the tissue retractor 2; thethickness of internal body tissue IBT pierced by needle 20 that willcontain a length CD of suture line 23 within internal body tissue IBTafter threading of a length of suture line 23 occurs; and the portion ofentire length of suture line 23 that will be selected for anchoring andsecuring tissue retractor 2 into anchoring port 90. A length AC ofsuture line 23 means the length of suture line between points A and C. Asegment within length AC will mean a portion of suture line 23 betweenpoint A and point C substantially shorter than the total length betweenpoint A and point C.

In broad terms, a typical example of the surgical procedure for theset-up and deployment of the surgical apparatus relating to the presentinvention consists of the surgeon:

Grasping the needle 20 with a surgical needle holder close to the bluntend 202, pierce the internal body tissue IBT to be retracted ordisplaced with the needle tip 201 at the point of entry into saidtissue;

a) Pushing said needle 20 through the internal body tissue IBT in amanner that the needle tip 201 exits through the internal body tissueIBT;

b) With the surgical needle holder, grasping the exposed portion of theneedle 20 between the needle tip 201 and its point of exit from theinternal body tissue IBT, and threading a length of suture line 23through the internal body tissue IBT, for example a length between pointA and point C on the suture line 23, also referred to as the threadedlength AC (FIG. 1A-1B). A length between point C and point D of sutureline 23 remains contained within the internal body tissue IBT, and willalso be referred to as the bearing length CD, and a length between pointD and point F of suture line 23 is not threaded through the internalbody tissue IBT, and will also be referred to as unthreaded length DF;

c) Pulling on the two lengths AC and DF simultaneously and sufficientlyto effectuate and maintain the desired internal body tissue IBTretraction, or to effectuate and maintain the desired displacement ofthe internal body tissue IBT from its anatomical disposition, or toeffectuate and maintain the desired displaced position or displacedorientation of a body organ through the retraction of internal bodytissue IBT that is anatomically attached to said body organ;

d) While maintaining the pulling loads on the two lengths AC and DF forthe desired internal body tissue IBT retraction (one length in eachhand), insert a segment within length AC of suture line 23 intoslit-like channel 72 (or 82) and over the opening of aperture 902 of oneof the anchoring ports 90 disposed on sternum retractor 1, (point B ofsuture line 23 is at this point situated over aperture 902—FIG. 1C);

e) While maintaining the pulling loads on the two lengths AC and DF forthe desired internal body tissue IBT retraction, bring thesuture-locating slot 251 of anchoring plug 25 in contact with thesegment of suture line 23 at point B over aperture 902, and insert andengage the anchoring plug 25 into said aperture 902 with a downwardforce thereby securing the desired internal body tissue IBT retractionor displacement according to (d);

f) if required, readjust the magnitude of retraction applied to theinternal body tissue IBT or readjust the magnitude of displacementexerted on the internal body tissue IBT by first disengaging anchoringplug 25 from aperture 902 and re-engage by repeating steps (d) to (f)above, with a different pulling force to effectuate and maintain thedesired readjustment in internal body tissue IBT retraction ordisplacement;

g) if required, readjust the direction of retraction load applied tointernal body tissue IBT or readjust the direction of displacementexerted thereon by first disengaging anchoring plug 25 from existingaperture 902 and re-engage said anchoring plug into another anchoringport 25 forming part of the plurality of such anchoring ports, byrepeating steps (d) to (f) above.

FIG. 1C illustrates one of the ways tissue retractor 2 can be deployed,as outlined above in broad terms. FIG. 1C illustrates the anchoring plug25 in the partially inserted position with the aperture 902. Only asegment within length AC of suture line 23 is engaged into slit-likechannel 72 and another segment of suture line 23 in the vicinity ofpoint B is pressed through the opening of aperture 902 by virtue of thislatter segment's engagement within suture-locating slot 251. The sutureline 23 of tissue retractor 2 is secured in a substantially fixedrelation to the anchoring port 90 by the action of sufficiently pressingdown on and wedging the anchoring plug 25 into aperture 902, in a mannerto pinch or trap the segment of suture line 23 that is engaged betweenthe outer surface 252 of plug 25 and surface of aperture 902, therebymaintaining the desired internal body tissue IBT retraction load ordisplacement. The deployment of tissue retractor 2 is now complete. Itis preferable in this method of deploying tissue retractor 2 that eachof the lengths AC and DF of suture line 23 is held by a separate handuntil the tissue retractor 2 is fully engaged with the anchoring port90, and its deployment complete. With the suture line 23 in tension fromthe retraction load the surgeon applies to the internal body tissue IBT,and with a segment within length AC of suture line 23 engaged inslit-like channel 72, a V-notch 905 in fitting 901 serves advantageouslyto align a segment within length AC of suture line 23 over the openingof aperture 902 poised to receive the suture-locating slot 251 of plug25 when said plug is inserted in aperture 902 with another hand.

FIG. 1D illustrates an alternate method of deployment of tissueretractor 2 in anchoring port 90. The anchoring plug 25 is shown priorto its insertion into aperture 902. Unlike the previous method ofdeployment described above in reference to FIG. 1C, both lengths AC andDF of suture line 23 are held by the surgeon in one hand, preferablybetween point A and B on one length and between point E and F on theother length, after the internal body tissue IBT is pierced with needle201 and a portion of suture line 23 denoted as length CD thereof iscontained within internal body tissue IBT. The surgeon pulls on bothlengths AC and DF simultaneously with one hand to apply and maintain thedesired retraction or displacement of the internal body tissue IBT,while inserting a segment within length AC and a segment within lengthDF in slit-like channel 72. Also by this action, a segment within lengthAC in the vicinity of point B and a segment within length DF in thevicinity of point E are disposed over aperture 902, ready to receivesuture-locating slot 251 of anchoring plug 25 as said plug is insertedin aperture 902 and engaged with anchoring port 90 by the action of theother hand. Like in the previous method of deployment, thesuture-locating slot 251 serves to locate the portions of suture line 23it contacts in a substantially diametric orientation with respect to thefree end of plug 25. The suture line 23 of tissue retractor 2 is securedin the same manner as in the first method of deployment described above,with the exception that two segments of suture line 23 (one in thevicinity of point B and the other in the vicinity of point E) will bepinched or trapped between the outer surface 252 of plug 25 and thesurface of aperture 902, thereby maintaining the desired internal bodytissue IBT retraction load or displacement.

Adjustment of the magnitude of the retraction force exerted on theinternal body tissue IBT or the magnitude of displacement of theinternal body tissue IBT from its original position in the body isaccomplished by disengaging anchoring plug 25 from the anchoring port90, thereby freeing the trapped segment or segments of suture line 23,and re-inserting and re-engaging said plug 25 into said port 90 in sucha manner as to trap or fix a different segment or segments of sutureline 23. Trapping or fixing a segment of suture line 23, within lengthAC, that is closer to point C (or simultaneously fixing a segment ofsuture line 23 within length AC that is closer to point C and anothersegment within length FD that is closer to point D) will result in anincrease in displacement of internal body tissue IBT from its originalposition within body, and usually also result in an increase in theretraction load applied o achieve such displacement.

Adjustment of the direction of the tissue retraction force exerted bythe suture line 23 on internal body tissue IBT is accomplished byremoving anchoring plug 25 from the anchoring port 90, thereby freeingthe trapped segment or segments of suture line 23, and re-inserting thesaid plug 25 into another anchoring port 90 situated at a differentlocation on the sternum retractor 1 in such a manner as to trap adifferent segment or simultaneously different segments of the sutureline 23. This effectively changes the orientation of the suture line 23with respect to the internal body tissue IBT, and consequently thedirection of the retraction force applied to the internal body tissueIBT. Adjustment of both the magnitude and direction of the retractionforce is possible by simultaneously moving anchoring plug 25 and sutureline 23 into another anchoring port 90 and by varying the suture lengthBC and DF (first method of deployment) or BC and DE (second method ofdeployment) between the internal body tissue IBT and the anchoring port90.

In both methods of deployment of the tissue retractor 2 illustrated inFIGS. 1C and 1D, the desired retraction or displacement of the internalbody tissue IBT is accomplished without the need to manually tie downsuture lines in the manner previously explained. In both said methods ofdeployment, adjustment of the magnitude of retraction of displacement ofthe internal body tissue IBT or adjustment of the direction ofretraction load applied on the internal body tissue IBT or its directionof displacement may be accomplished without having to dispose ofexisting suture and re-piercing the internal body tissue IBT with anewly deployed suture.

As mentioned in the description of this first embodiment, and asillustrated in FIGS. 1A-1D, the fitting 901 preferably assumes asubstantially horizontal orientation, and the longitudinal axis ofaperture 902 is preferably substantially vertical. Alternatively, thefitting 901 can assume an orientation that is other than horizontal, orthe longitudinal axis of aperture 902 can assume a non-verticalorientation, or even both the fitting 901 orientation and aperture 902orientation may be varied simultaneously, while still maintaining theprinciples and obtaining the desired results of the present invention asdescribed above.

In this first embodiment according to the present invention, theanchoring port 90 and the anchoring plug 25 cooperate and together serveas an anchoring mechanism. A variety of geometries for the anchoringport 90 and anchoring plug 25 are possible which serve the intendedpurpose of trapping, wedging, clamping, pinching, or otherwisesubstantially fixing a segment of the suture line 23 relative to asubstantially stable surgical platform, such as a sternum retractor 1.FIGS. 2A to 2C illustrate a few geometric variations for the saidanchoring plug. FIG. 2A illustrates a tapered anchoring plug 26 with amultitude of substantially circumferential ridges 261 spaced along plugouter surface 262. Two adjacent ridges 261 serve to trap a segment ofsuture line 23 therebetween, and at least one of the said ridges servesto pinch the two endpoints of said trapped segment between the surfaceof ridge 261 and the surface of aperture 902, when anchoring plug 26 isfully engaged in anchoring port 90. FIG. 2B illustrates a taperedanchoring plug 27 comprised of a series of progressive conical wedges271. FIG. 2C illustrates a tapered hexagonal anchoring plug 28. For eachof these variant anchoring plug geometries, the corresponding aperture902 geometry must cooperate with these said plug geometries to achievethe intended use of substantially fixing the segment of suture line 23engaged within aperture 902 relative to the sternum retractor 1, therebymaintaining the tensile retraction load in the suture line 23 and thedesired internal body tissue IBT retraction. For example, the saidaperture cooperating with hexagonal anchoring plug 28 is also preferablysubstantially hexagonal in cross section tending to improve the fitbetween said cooperating components. The anchoring plugs 25,26,27 and 28shown in the preceding figures are preferably manufactured in a polymeror substantially rubber-like compound in order to tend to improve theirconformance and adherence to the mating geometry of cooperating aperture902. The said anchoring plugs may be at least partially elastic,partially malleable, or partially compliant in the sense that at leastthose portions of the anchoring plugs which contact the cooperatingaperture will exhibit the desired characteristics of elasticity,malleability, or compliance. With such a construction, the saidanchoring plugs are typically not well-suited for conventional steamsterilization and are typically disposable elements. In addition tohaving a geometry to suit the said anchoring plug geometry of specificvariants, the surfaces of the said aperture can be manufactured orcoated with a surface texture to further enhance friction, fit, oradherence with the engaged said anchoring plug.

In this first embodiment the components comprising the tissue retractor2, for instance is the curved needle 20, the suture line 23, and theanchoring plug 25 form an integral assembly, which can be advantageouslypackaged in sterilized packets similar to standard suture packets. Thisintegral assembly would be a single use disposable implement as is thecase with existing sutures. The components comprising the anchoring port90, which may be either integral or mechanically assembled to a surgicalplatform such as a preferably reusable sternum retractor 1, would alsobe preferably reusable. As explained below, the tissue retractor 2offered in disposable form and available in ready-to-use sterilizedpackets also provides the possibility for classifying some of thevariables of the tissue retractor configuration. For instance, thetissue retractor can be offered in a variety of classified suture line23 lengths, a variety of classified suture line 23 materials, a varietyof classified suture line 23 widths, a variety of tissue-piercing needle20 configurations, to name but a few examples. This allows the surgeonto select the most suitable sterilized packet to perform the specifictissue retraction operation, similar to the current classification andselection practice that is followed with traditional surgical sutures.In another variant, the suture line 23 with integral needle 20 isoffered as traditional disposable suture, and the anchoring plug is aseparate reusable component, manufactured in metal, and endowed withcompliant properties by virtue of its mechanical design in order to aimto enhance its fit and cooperation with the aperture geometry. Inanother variant, the needle 20 can be detachable from the suture line 23at point A, after the tissue retractor 2 is completely deployed, inorder to remove the risk of having a sharp tip 201 exposed during thesurgical intervention.

FIGS. 3A-3C illustrate further variants of tissue retractor 2 byreplacing anchoring plug 25 with anchoring plugs 29, 30 or 31 thatinclude handle members 291, 301 and 311, respectively. Handle members291, 301 and 311 tend to facilitate the manipulation of said anchoringplugs 29, 30 and 31 especially with regards to insertion and removal ofsaid plugs from anchoring port 90, by either a human hand or through theuse of a surgical implement. Suture line 23 is attached to said handlemembers at point A, preferably along the central longitudinal axisdefining said anchoring plugs. The said handle members are preferablyconfigured with circular outer profiles 293, 303 and 313, but may alsobe configured with other non-circular outer profiles suitable tofacilitate manipulation of said anchoring plugs. The handle members 291,301, 311 are also preferably manufactured integral with the anchoringplugs 29, 30, 31. FIG. 3A illustrates a basic disc shaped handle member291; FIG. 3B illustrates a disc shaped handle member 301 with integraltraction ridges 302 tending to reduce slippage during manualmanipulations, especially with wet surgical gloves; FIG. 3C illustratesan annular handle member 311 permitting the insertion of either a humanfinger or surgical implement through opening 312 to tend to facilitatedisengagement of plug 31 from anchoring port 90.

The said handle members may also advantageously serve to allow thesurgeon to apply a rotation, about the longitudinal axis of the saidanchoring plug, at some point during the insertion procedure of saidanchoring plug into anchoring port 90, before the complete deployment ofthe tissue retractor is accomplished. This enables an anchoring plugwith a circular cross-sectional area (in a plane perpendicular to itslongitudinal axis) except for a local raised dimple or longitudinalbulge along its outer surface, to be easily inserted in one discreteorientation relative to the anchoring port 90 by virtue of the aperture902 having a volumetric provision to accommodate said dimple or saidbulge in said discrete orientation relative to anchoring port 90.Rotation of the handle member can serve to compress anchoring plugacross its dimple or bulge, as anchoring plug is forced to assume a neworientation within anchoring port 90 whereby said volumetric provisionin said aperture opening is no longer engaged by the anchoring plugdimple or bulge. This rotation thereby tends to secure the anchoringplug within the anchoring port, and with a segment of suture line 23pinched between said plug and said aperture, the intended purpose of theinvention is fulfilled.

FIG. 4A illustrates a further variant of tissue retractor 2 by replacinganchoring plug 25 with anchoring plug 32. Like the previous embodiments,anchoring plug 32 preferably forms an integral assembly with suture line23 which originates from its top face 323, and curved needle 20 attachedto other end of suture line 23 (not shown). Anchoring plug 32 isadvantageously manufactured with a longitudinal slot 322 preferablyextending along the entire length of said plug. The outer surface 321 ofplug 32, in its free unconstrained state prior to its insertion andengagement with anchoring port 90, defines a cross section (transverselyto plug longitudinal axis and neglecting cross section of slot 322) thatis substantially larger than the cooperating transverse cross section inaperture 902. The material of the plug is substantially elastic orsubstantially malleable such that when said plug 32 is inserted andengaged in aperture 902, the outside surface 321 will be compressed andconstrained into assuming a smaller cross section, due largely to theresulting narrowing of circumferential width of slot 322. Consequently,a segment within length AC of suture line 23 (or a segment within lengthAC and segments within length DF of suture line 23) engaged within slot322 will be clamped by the opposing surfaces defining slot 322. Thesuture line 23, loaded in tension by the retraction load it applies tothe internal body tissue IBT, will thereby be fixed relative to thecompletely engaged plug 32 in port 90, and thereby tending to maintainthe desired internal body tissue IBT retraction. This configuration ofanchoring plug 32 may be advantageous in tending to reduce slippage andtending to increase the pinching or clamping force exerted on the sutureline 23 to keep the engaged length of said suture line fixed or securedrelative to the anchoring plug 32 and anchoring port 90. Adjustment ofthe magnitude of the retraction force exerted by the suture line 23 onthe internal body tissue IBT or the magnitude of displacement of theinternal body tissue IBT from its original position in the body isaccomplished by disengaging anchoring plug 32 from port 90 anddisplacing through slot 322 at least one of the engaged segments ofsuture length 23 to thereby engage a different segment of suture line23. Adjustment of the direction of the tissue retraction force exertedby the suture line 23 on the internal body tissue IBT is accomplished bydisengaging plug 32 and re-engaging said plug into another anchoringport 90 situated at a different location on the sternum retractor 1, insuch a manner as to clamp different segments of suture line 23 in themanner described above. The inner surfaces of longitudinal slot 322 canbe substantially smooth, as illustrated in FIG. 4A, or alternatively canbe textured, rough or serrated to tend to increase the friction forceexerted on engaged suture line 23 when it is clamped between saidsurfaces during engagement of plug 32 into port 90. The slot 322 isillustrated in a substantially longitudinal configuration relative toplug 32 but may alternatively assume a substantially helical dispositionabout the longitudinal axis of said plug 32.

FIG. 4B illustrates a further variant of tissue retractor 2 by replacinganchoring plug 25 with anchoring plug 33 and, like the previousembodiments, preferably forms an integral assembly with suture line 23and curved needle 20 (not shown). Plug 33 is configured with asuture-locating slot 331 substantially transverse to the longitudinalaxis of the plug 33. Relative to suture-locating slot 251 of the firstembodiment, slot 331 tends to improve the cooperation of plug 33 withthe engaged segment or segments of suture line 23 during insertion andremoval of said plug into anchoring port 90. During insertion of plug 33into anchoring port 90, the engaged segment of suture line 23 is incontact with concave surface 332 of said slot 331. During disengagementof plug 33 from port 90, the engaged segment of suture line 23 is incontact with concave surface 333 of said slot 331. Unlike the firstembodiment illustrated in FIG. 1A-1D, when plug 33 is fully engaged inport 90, the engaged segment or segments of suture line 23 locatedwithin slot 331 are contained within the surfaces defining aperture 902,and said engaged segment or segments are not exposed below the fitting901 as is the case in this first embodiment where suture locating slot251 is configured on the free end of plug 25. Alternatively, slot 331may be replaced by a substantially transverse hole. In this variant,after the internal body tissue IBT tissue is pierced and a length AC ofsuture line 23 threaded through said internal body tissue IBT, thecurved needle 20 is then inserted through said hole along with a lengthAB of suture line 23 which is also threaded through said hole prior toinsertion and engagement of anchoring plug in anchoring port 90.

In the remaining embodiments, the portion of the internal body tissueIBT that is pierced by needle 20 and threaded by suture line 23 is notillustrated. However, if illustrated the internal body tissue IBT wouldcontain and shield length CD of suture line 23, also previously definedas the bearing length CD. Point C is the point along the length ofsuture line 23, of a fully deployed tissue retractor 2, that lies at thepoint of exit of said suture line 23 from the retracted internal bodytissue IBT. Point D is the point along the length of suture line 23, ofa fully deployed tissue retractor 2, that lies at the point of entry ofsaid suture line 23 into the retracted internal body tissue IBT.

FIG. 5A illustrates a second embodiment according to the presentinvention. The tissue retractor 12 is comprised of a tissue-piercingmember such as a curved needle 20, a wire-like filament such as a sutureline 23, an anchoring member such as anchoring plug 34, and an anchoringport 91. Unlike the first embodiment, the anchoring plug 34 in thissecond embodiment is not rigidly attached to the suture line 23 at afixed location along its length, but is slidingly engaged to said sutureline 23 and thereby capable of assuming any location along the entirelength AF of suture line 23. Anchoring plug 34 is substantiallydiamond-shaped with substantially planar faces 341, 342, 343, and 344forming the suture-contacting perimeter of said diamond shape. A sutureguide passage 346 extends through anchoring plug 34, and is of asuitable width dimension to allow insertion of suture line 34 throughsaid passage 346. The longitudinal axis of passage 346 substantiallybisects the wedge angle formed by face 341 and 344, and also by face 342and 343. Preferably, the assembly fit that results between the insertedportion of suture line 23 and passage 346 is not loose, and the forcerequired to slide the anchoring plug 34 along at least a length ofsuture line 23 may be easily overcome by the manual force applied bysurgeon. Once the anchoring plug 34 is inserted on the suture line 23,the width of the suture line 23 at its free end 349 is preferablyenlarged to prevent plug 34 from disengaging suture line 23 duringsubsequent manipulations or deployment of tissue retractor 12. This maybe achieved either through the formation of a knot placed in suture line23 in the vicinity of its free end 349, or alternatively during themanufacturing process of tissue retractor 12 when an end fitting, suchas a spherical end cap (not shown) of larger width dimension than sutureline 23 can be permanently mounted to the said free end 349. Cooperatingwith anchoring plug 34 to accomplish the desired internal body tissueIBT retraction is anchoring port 91. FIG. 5B schematically illustrates asubstantially rigid and substantially stable platform 11, for instanceat a location on the sternum retractor 1, onto which is disposedanchoring port 91. FIG. 5B also schematically represents a top view of asectioned anchoring port 91. Port 91 is configured with a narrowslit-like channel 912, which may also be an extension of slit-likechannel 72 in outward direction from surgical window SW. In movingoutwardly relative to surgical window SW, the faces defining the widthof slit-like channel 912 diverge to form a wedge shaped aperture 914defined by two diverging faces 911. Surface 913 forms the bottom face ofslit-like channel 912 and the bottom face of wedge aperture 914, therebyalso serving as a location datum for lateral faces 345 of anchoring plug34, when said plug is engaged in said port. The geometry of the wedgeaperture 914 and the geometry of diamond shape anchoring plug 34substantially coincide to properly cooperate during the deployment ofthe tissue retractor 12.

FIG. 5B illustrates a fully engaged tissue retractor 12 within wedgeshaped aperture 914, according to a first preferred method ofdeployment. As previously explained, the anchoring plug 34 may bemanufactured in a material or design that makes it at least partiallymalleable or partially elastic to tend to improve its conformity tocooperating faces 911 and its compliance around the engaged suture linethat it will pinch against faces 911. In broad terms, this preferredmethod deployment for this second embodiment according to the presentinvention, consists of:

a) piercing the internal body tissue IBT with needle 20 and threading alength AC of suture line 23 through said internal body tissue IBT;

b) retracting pierced internal body tissue IBT by simultaneously pullingon both lengths AC and DF of suture line 23;

c) selecting the most convenient anchoring port 91 from the pluralitydisposed around sternum retractor 1, estimating the required location ofanchoring plug 34 along suture line 23 to be able to secure the desiredinternal body tissue IBT retraction by engagement of anchoring plug 34into the selected anchoring port 91;

d) sliding the anchoring plug 34 along suture line 23 to the saidrequired location;

e) in length DF of suture line 23 (between internal body tissue IBT andfree end 349), rotating the diamond shape anchoring plug 34 such thatpoint E1 on suture line 34 comes in contact with face 342, and point E2comes in contact with face 343;

f) bringing length AC of suture line 23 (between internal body tissueIBT and needle 20) in contact with anchoring plug 34 such that point Bcomes in contact with face 343;

g) while holding anchoring plug 34 in the relationship described in (f)above, simultaneously pulling on both lengths of suture line 23,preferably between point B and C on one length and point D and E1 on theother length, to exert the desired internal body tissue IBT retraction;

h) while maintaining the desired internal body tissue IBT retraction,inserting simultaneously a portion of each length BC and DE1 inslit-like channel 912, and also inserting anchoring plug 34, with theabove said relationship to suture line, in wedge aperture 914 (lengthsE2F and AB of suture line 23 extending beyond port 91 preferably inoutwardly direction from surgical window SW);

i) releasing anchoring plug 34;

j) if required, readjusting the magnitude of retraction load exerted oninternal body tissue IBT by first pulling simultaneously on lengths BCand DE1 of suture line 23, in a manner to increase retraction loadslightly thereby loosening wedging action between plug 34 and port 91.Secondly disengaging plug 34 from port 91 and repeating steps (b) to (h)above;

k) if required, readjusting the direction of retraction load applied tointernal body tissue IBT or readjusting the direction of displacementexerted on internal body tissue IBT by performing step (j) above butonly re-engaging anchor 34 into another port 91 located along theperimeter of sternum retractor 1.

In this preferred method of deployment, the tensile load in length BCand DE1 of suture line 23, due to the retraction exerted on internalbody tissue IBT, tends to wedge diamond faces 343 and 342 into wedgefaces 911 of port 91 thereby pinching or clamping suture line engagedbetween 911 and said wedge diamond faces. In addition, this said tensileload in length BC and DE1 tends to impart a moment on anchoring plug 34and rotate it in a clockwise direction as it is illustrated in FIG. 5B,within wedge aperture 914. This tends to increase the pinching action byanchoring plug 34 on engaged suture line 23, especially at cornerlocations 347 and 348. Suture-contacting perimeter faces 341, 342, 343,or 344 may be textured, rough or serrated to tend to increase thefriction force exerted on engaged suture line 23 when it is clampedbetween some of the said perimeter faces and faces 911 of wedge aperture914, which may also be textured.

A second alternate method of deployment (not illustrated), in broadterms, consists of eliminating step (e), that is, eliminating therotation of diamond plug 34 so that E1 is in contact with 342 and E2 isin contact with 343. In this second method, point B is in contact withperimeter face 341 but length DF passes directly through passage 346without being wrapped around any of the perimeter faces 341, 342, 343,or 344. In this method of deployment, it is preferable to have ananchoring plug 34 configured with a longitudinal slit through one of theside faces 345, preferably in communication with the entire length ofpassage 346. This configuration attempts to augment the clamping forceon the length of suture line 23 engaged in passage 346 by virtue of thewedging action on faces 343 and 342 transmitting a closing force acrossthis said longitudinal slit. Therefore, in this method of deploymentlength AC is pinched or clamped at location B between face 341 and wedgeface 911 of aperture 914 and the other length DF is clamped over theengaged length contained in passage 346, that falls between points E1and E2.

In this second embodiment according to the present invention, theanchoring port 91 and the anchoring plug 34 cooperate and together serveas an anchoring mechanism. Other geometric variations of the anchoringplug 34 and the cooperating anchoring port 91 are possible withoutdeparting from the spirit of this second embodiment. FIGS. 5C and 5Dillustrate two such variations; a rectangular-shaped plug 35 is shown inFIG. 5C while a triangular wedge-shaped plug 36 is shown in FIG. 5D.Other geometric variations for the anchoring plug may include anelliptical-shaped anchoring plug. All these variants may be deployed inat least one of the methods of deployment described above.

FIG. 6A illustrates the third embodiment according to the presentinvention. Internal body tissue IBT retraction will be effectuated witha traditional suture 13, comprised of a curved suture needle 20 and asuture line 23, that becomes engaged with anchoring mechanism 92disposed on sternum retractor 1, in a plurality of locations similar tothe disposition of anchoring ports 90 of the first embodiment. FIG. 6Aillustrates only the most remote portion relative to rack bar 5 ofretractor spreader arm 3, with one anchoring mechanism 92 disposedlaterally outward on said arm 3.

Anchoring mechanism 92 is comprised of the following components: ahousing 922, a pinch roller 934, a traction roller 93, a retention pin928, and a shoulder bolt 932. The housing 922 may be either an integralextension of retractor arm 3 (or 4) or may be mechanically fastened tosaid retractor arm to form a rigid assembly during at least the durationof the surgical intervention requiring tissue retraction.

Housing 922, serving to retain or to partially house the cooperatingcomponents of anchoring mechanism 92, is defined by: a base platform 921which disposes threaded hole 927 for engagement of shoulder bolt 932 andhole 926 for engagement of retention pin 928 (FIG. 6B); a wall member925 (FIG. 6B) which is configured with traction surface 923 over atleast a portion of its entire surface; and a top plate 924. Asubstantially tubular pinch roller 934 is mechanically assembled to thebase platform 921 by shoulder bolt 932, whose thread 933 engages withthreaded hole 927 (FIG. 6B), said shoulder bolt rigidly engaged to baseplatform 921 after assembly. Axial movement of pinch roller 934 islimited in one direction by the shoulder 935 and in the other directionby platform 921. Lateral movement of pinch roller 934 (i.e.perpendicular to its centerline) is limited by the clearance between theouter diameter of shank 936 and inner diameter 937 of pinch roller 934.This said clearance is preferably minimized but sufficient to allowpinch roller 934 to rotate freely about its centerline relative toshoulder bolt 932. Cylindrical traction roller 93, with traction ridges931 configured on its circumferential surface, is subsequently insertedinto the slot created by top plate 924 and base platform 921. Acylindrical retention pin 928 is subsequently inserted into hole 926(FIG. 6B), and preferably permanently fixed in said hole, either by astaked mechanical press fit, brazing, welding, or riveting for instance,in order to permanently trap traction roller 93 within anchoringmechanism 92. In the same manner, threaded shoulder pin 932 may bereplaced by a stepped shoulder pin that is also permanently fixed tohousing 922 after having been inserted through pinch roller 934, inorder to permanently trap pinch roller 934 to housing 922. This openconfiguration of anchoring mechanism 92 as illustrated in FIG. 6A tendsto facilitate sterilization and cleaning of this surgical apparatus ifthe anchoring mechanism is manufactured with reusable materials andcomponents.

Within the anchoring mechanism 92 mechanical assembly, traction roller93 is capable of limited lateral translation (perpendicular to itscenterline) in a plane substantially parallel to base platform 921.Lateral translation of the traction roller 93 is limited by the pinchroller 934, the retention pin 928, and traction surface 923. Withinthese limits the traction roller 93 is free to rotate about itscenterline, unless it is engaged with suture line 23 and anchoringmechanism 92 assumes its fully deployed configuration. Axial translationof traction roller 93 (along its centerline) is limited by the baseplatform 921 and top plate 924 Top plate 924 extends sufficiently overthe faces of traction roller 93 to prevent it from exiting the fullyassembled anchoring mechanism 92, while still allowing the insertion ofretention pin 928 and shoulder bolt 932 into base platform 921. Thelocation of pinch roller 934 on base platform 921, relative to slit-likechannel 72, is such that a suture line 23 inserted in said channel 72and pulled taut laterally outward through the anchoring mechanism 92 andparallel to said channel 72 would contact pinch roller 93 in asubstantially tangent orientation. Substantially planar base platform921 is preferably parallel to the top surface of arcuate rail 71, andpreferably offset to a depth at least below the maximum depth ofslit-like channel 72, so that a suture line 23 engaged in anchoringmechanism 92 is capable of assuming the deepest position withinslit-like channel 72 to tend to minimize its obstruction in arcuatepassage 71.

In broad terms, the method of deployment for this third embodimentaccording to the present invention, consists of:

a) piercing the internal body tissue IBT with needle 20 and threading alength AC of suture line 23 through said internal body tissue IBT;

b) simultaneously inserting both lengths AC and DF of suture line 23firstly in slit-like channel 72 and secondly in between pinch roller 934and traction roller 93;

c) grasping both lengths AC and DF of suture line 23, in the vicinity ofpoint A and point F, and retracting pierced internal body tissue IBT bypulling simultaneously both said lengths longitudinally outward throughslit-like channel 72 while all the time maintaining suture-line lengthsin contact with pinch roller 934 by laterally loading said suture linesagainst said pinch roller during the said pulling action;

d) once the desired internal body tissue IBT retraction or internal bodytissue IBT displacement is obtained, displace the grasped suture lines23 laterally away from pinch roller 934 towards traction roller 93, suchthat at least a segment of suture line 23 between point A and point Band at least a segment of suture line 23 between point E and point Fengages and exerts a force towards the center of traction roller 93,thereby bringing traction surface 931 into contact with traction surface923 by virtue of the lateral translation of traction roller 93;

e) while maintaining both lengths of suture line 23 laterally forcedagainst traction roller 93, gradually and slightly reduce the retractionforce on the grasped lengths of suture line 23, causing both saidlengths to be slightly retrieved longitudinally inward through slit-likechannel 72 and entraining traction roller 93 to roll on traction surface923 towards pinch roller 934;

f) simultaneously releasing grasped lengths AC and DF of suture line 23when traction roller 93 is only separated from pinch roller 934 by thewidth of suture line 23 trapped between said rollers at point B andpoint E of suture line 23.

During step (c) of the method of deployment described above, the lateralloading of suture lines 23 against pinch roller 934 generates a forceradially inward towards the centerline of pinch roller 934, whichentrains a rotation of pinch roller 934 about its centerline if thefriction between contacting suture line 23 and the outer diameter ofpinch roller 934 is sufficient to overcome the friction between pinchroller 934 and shoulder bolt 932.

During step (d) of the method of deployment described above, theresultant friction force between suture line 23 and traction ridges 931when suture lines are laterally forced against traction roller 93,entrains said traction roller to roll towards pinch roller 934, byvirtue of the engagement or substantial meshing between ridges 931 andtraction surface 923. Once the grasped lengths AC and DF of suture line23 are released, with suture line pinched between traction roller 93 andpinch roller 934, the friction between traction roller surface 931 andsuture line 23, along with the tensile load applied on suture lines 23from the resistance of the internal body tissue IBT to imposedretraction, will try to entrain traction roller 93 to roll even closerto pinch roller 934 by virtue of its continued engagement with tractionsurface 923, and thereby tend to increase the pinching load on sutureline 23 between traction roller 93 and pinch roller 934.

Disengagement is accomplished by grasping the lengths AC and DF ofsuture line 23 in the vicinity of point A and point F, andsimultaneously pulling on said lengths to increase the retraction loadon the internal body tissue IBT beyond the load currently deliveredthrough the traditional suture 13 being engaged in the fully deployedanchoring mechanism 92. This action relieves the internal body tissueIBT retraction force from the surgical apparatus back to the surgeon'shand, and entrains traction roller to roll away from pinch rollerthereby releasing the pinching or wedging effect between 931 and 934responsible for securing or fixing suture line relative to the anchoringmechanism. Readjustment of the magnitude of internal body tissue IBTretraction or internal body tissue IBT displacement may at this point beaccomplished by repeating steps (c) to (f) above. Readjustment for thedirection of the applied internal body tissue IBT retraction load or forthe direction of exerted displacement on the internal body tissue IBTmay be accomplished by disengaging the suture line 23 in mannerdescribed above, and repeating steps (c) to (f) above but engaginganchoring mechanism 92 located in another position on sternum retractor1.

To facilitate the insertion of suture line 23 between the pinch roller934 and the traction roller 93, the pinch roller 934 is configured witha dome shaped shoulder 935 and the traction roller 93 is configured witha beveled edge 938. Alternatively, the height of pinch roller 934 orshoulder bolt 932 may extend above the plane of top plate 924 tofacilitate insertion of suture line 23 between said pinch and tractionrollers. In both cases, height of pinch roller 934 is preferably atleast equal to the height of traction roller 93.

The traction ridges 931 on the traction roller 93 are preferablysubstantially V-shaped longitudinal ridges, and the traction surface 923on wall 925 is preferably configured with longitudinal substantiallyV-shaped grooves extending from the base platform 921 to the top plate924 of housing 922. A variety of other cooperating surface textures orcooperating surface profiles configured on the cylindrical surface oftraction roller 93 and the textured portion of wall 925, may also beused to provide a substantial meshing between said components orsubstantially slip free rolling of traction roller 93 on tractionsurface 923 when said roller is loaded against said traction surfaceduring the deployment of tissue retractor 13, in manner described above.

FIGS. 7A-7B illustrate a fourth embodiment according to the presentinvention. Internal body tissue IBT retraction will be effectuated witha traditional suture 13, comprised of a curved suture needle 20 and asuture line 23, that becomes engaged with anchoring mechanism 94disposed on sternum retractor 1, in a plurality of locations similar tothe disposition of anchoring ports 90 of the first embodiment. FIG. 7Aillustrates only the most remote portion relative to rack bar 5 ofretractor spreader arm 3, with one anchoring mechanism 94 disposedlaterally outward on said arm 3.

Anchoring mechanism 94 is comprised of a fitting 943, and twopawl-shaped levers: an anvil-like pawl 941 and a wedge-like pawl 942.Fitting 943 may be either an integral extension of retractor arm 3 (or4) or may be mechanically fastened to said retractor arm to form a rigidassembly during at least the duration of the surgical interventionrequiring tissue retraction. Fitting 943 is preferably disposed belowthe depth of slit-like channel 72. Anvil-like pawl 941 and wedge-likepawl 942 are preferably rotatingly engaged with fitting 943 by pivotpins 944 and 947, respectively, which are inserted through cylindricalbores in said pawls (not shown). Pivot pins 944 and 947 are rigidlymounted to fitting 943 through a variety of ways, such as: a threadedinterface, by riveting, by brazing, or other like ways, in order to keepthe components comprising the anchoring mechanism 94 as an integralmechanical assembly. The centerlines of the pivot pins 944 and 947 areparallel to each other. Anvil-like pawl 941 is configured with a jaw 945which comprises a planar face portion, and wedge-like pawl 942 isconfigured with a jaw 946 which comprises a sharp wedge, said jawscooperating together and capable of providing a concentrated clampingload to a suture line 23 which becomes engaged between said jaws, asillustrated in FIG. 7B. Also disposed between pivot pin 944 andcylindrical bore of anvil-like pawl 941 is a torsion spring (not shown),engaging between pawl 941 and pivot pin 944, or alternatively betweenpawl 941 and fitting 943. Similarly, disposed between pivot pin 947 andcylindrical bore of wedge-like pawl 942 is another torsion spring,engaging between pawl 942 and pivot pin 947, or alternatively betweenpawl 942 and fitting 943. The said torsion springs serve to rotate pawls941 and 942, in opposing directions, until their respective jaws 945 and946 come and remain in contact. The angular rotation of at least one ofthe pawls 941 or 942, about its respective pivot pin 944 or 947,preferably anvil-like pawl 941, is contained within a range of angularpositions thereby ensuring that the sharp wedge portion of jaw 946 willonly contact the flat face portion of cooperating jaw 945 (when thesuture is not engaged) by the action of the said torsion springs. Theangular rotation of at least one of the pawls 941 or 942 may becontained within the desired range of angular positions by limit stopsor limit pins (not shown), for example, disposed on the top face offitting 943 and capable of contacting at least a portion of the affectedpawl at the limit position of the said range of angular positions.Alternatively, an external circumferential notch on pivot pin 944 or947, that is contacted by a narrower protrusion on pawl 941 or 942respectively that extends into the cylindrical bore of said pawl 941 or942, may serve to limit the desired angular range of position for theaffected pawl.

By virtue of said torsion springs, jaws 945 and 946 are capable ofapplying a spring-induced clamping force to a suture line 23 whichbecomes inserted between said jaws. The magnitude of this spring-inducedclamping force may be increased by increasing the spring stiffness ofsaid torsion springs. The topmost portion of jaws 945 and 946 may bechamfered or profiled (not shown) to facilitate insertion of suture line23 between spring loaded pawls 941 and 942.

In broad terms, the method of deployment for this fourth embodimentaccording to the present invention, consists of:

a) piercing the internal body tissue IBT with needle 20 and threading alength AC of suture line 23 through said internal body tissue IBT;

b) simultaneously inserting both lengths AC and DF of suture line 23firstly in slit-like channel 72 and secondly in between jaw 945 ofanvil-like pawl 941 and jaw 956 of wedge-like pawl 942;

c) rasping both lengths AC and DF of suture line 23, in the vicinity ofpoint A and point F, and retracting pierced internal body tissue IBT bypulling simultaneously both said lengths longitudinally outward throughslit-like channel 72 and through jaws 945 and 946, sufficiently toobtain the desired internal body tissue IBT retraction or displacement;

d) simultaneously releasing both lengths AC and DF of suture line 23,jaws 945 and 946 being in contact with the suture line 23 at point B andpoint E of said suture line;

e) if required, readjusting to increase the magnitude of internal bodytissue IBT retraction or displacement, by simultaneously grasping sutureline 23 between lengths AB and EF, and pulling simultaneously both saidlengths in manner described in step (c) above;

f) if required, readjusting to decrease the magnitude of internal bodytissue IBT retraction or displacement, by: (i) simultaneously graspingsuture line 23 between lengths AB and EF, and pulling simultaneouslyboth said lengths upward away from fitting 943, in a pulling directionsubstantially parallel to centerline of pivot pins 944 and 947, todisengage suture line 23 from contact with jaws 945 and 946 of pawls 941and 942, respectively, (ii) relieving internal body tissue IBTretraction load by applying no pulling force on said grasped suture line23, (iii) re-engaging suture line 23 with jaws 945 and 946 to securedesired internal body tissue IBT retraction or displacement by repeatingsteps (c) and (d) described above;

g) if required, readjusting the direction of retraction load applied tointernal body tissue IBT or readjusting the direction of displacementexerted on internal body tissue IBT by disengaging suture line 23 fromexisting anchoring mechanism 94 and re-engaging suture line 23 inanother anchoring mechanism 94 disposed in an alternate location onsternum retractor 1, by repeating steps (c) to (f) described above.

Alternatively, steps (b) and (c) of the method of deployment describedabove may be reversed by first pulling simultaneously and sufficientlyboth lengths AC and DF longitudinally outward from surgical window SW toobtain the desired internal body tissue IBT retraction or displacement,and subsequently inserting simultaneously both said lengths of sutureline 23 firstly in slit-like channel 72 and secondly in between jaws 945and jaw 946 of anchoring mechanism 94.

During step (b) of the first method of deployment described above, aspring-induced clamping force is applied to the portions of suture line23 inserted between jaws 945 and 946, by virtue of the torsion springacting between pawl 941 and pivot pin 944 and the torsion spring actingbetween pawl 942 and pivot pin 947. There is no tension in suture line23 since the internal body tissue IBT is not yet retracted. In thealternate method of deployment, only the spring-induced clamping forceacts on the portions of suture line 23 inserted between jaws 945 and 946as long as the tension in lengths AC and DF of suture line 23 resultingfrom the imposed retraction on internal body tissue IBT, or from thedisplacement exerted on internal body tissue IBT, is reacted by thesurgeon's hand and not the anchoring mechanism 94.

During step (d) of the first method of deployment described above, theresulting tension in lengths AC and DF of suture line 23 from theimposed retraction on internal body tissue IBT, or from the displacementexerted on the internal body tissue IBT, is reacted by anchoringmechanism 94. When tension is applied to the suture line 23simultaneously at point C and point D by the retracted internal bodytissue IBT, the friction force between the suture line 23 (at points Band E) and each of jaws 945 and 946 will cause the pawls 941 and 942 torotate in opposition, beyond the point of rotation of said pawls whenonly the action of the torsion springs places said jaws of said pawls incontact with the portion of inserted suture line 23. Consequently, thenormal force on the suture line 23 at point B and point E will beincreased beyond the spring-induced clamping force. The distance betweenthe axis of pivot pin 947 and jaw 946 is only slightly larger than halfthe distance between the axis of pivot pin 944 and the axis of pivot pin947, and similarly the distance between the axis of pivot pin 944 andjaw 945 is only slightly larger than half the distance between the axisof pivot pin 944 and the axis of pivot pin 947 such that the increase innormal force on point B and point E of suture line 23 caused by tensionapplied to the said suture line simultaneously at point C and point Dwill always result in a clamping friction force which is greater thanthe tension applied to the suture line 23, where the said clampingfriction force is equivalent to the normal force on the suture line 23at point B and point E multiplied by the coefficient of friction betweeneach of the said jaws and the suture line 23 at point B and point E.With the said clamping friction force greater than the tension on thesuture line 23, the suture line 23 is fully engaged in anchoringmechanism 94, and the suture line 23 should not slip through the jaws945 and 946 of pawls 941 and 942 thereby securing the desired internalbody tissue IBT retraction or internal body tissue IBT displacement.

The disengagement of suture line 23 according to step (f) in abovedescription of the method of deployment may be facilitated by applying acompression force between extension 948 and extension 949 of pawls 941and 942, respectively. This compression force causes pawls 941 and 942to rotate in opposition thereby releasing portion of suture line 23inserted or engaged between their respective jaws 945 and 946.

In this fourth embodiment as illustrated in FIGS. 7A-7B, the line ofcontact that results between jaw 945 which comprises a planar faceportion and jaw 946 which comprises a sharp wedge portion, when saidjaws come into contact by the rotation of pawls 941 and 942 about theirrespective pivot pin 944 and 947, is preferably parallel to thecenterline of said pivot pins. As illustrated, the line of contact ispreferably configured over the entire height of jaws 945 and 946, butmay also be reduced provided at least a portion remains available forengagement of suture line 23 between said jaws.

Other variants for the line of contact are also possible withoutdeparting from the spirit of this embodiment of the present invention.For example, a grooved recess may be configured across the planar faceportion of jaw 945 (said grooved recess substantially perpendicular tothe centerline of pivot pin 944) serving to locate a portion of sutureline 23 therein. The cooperating sharp wedge portion of jaw 946 will beconfigured with a protruding wedge profile that conforms to groovedrecess profile, such that the distance between the axis of pivot pin 947and protruding wedge profile of jaw 946 is only slightly larger thanhalf the distance between the axis of pivot pin 944 and the axis ofpivot pin 947, and similarly the distance between the axis of pivot pin944 and grooved recess of jaw 945 is only slightly larger than half thedistance between the axis of pivot pin 944 and the axis of pivot pin947.

Alternatively, without departing from the spirit of this fourthembodiment, those skilled in this act will appreciate that pawls 941 and942 may provide opposed cam-like surfaces which serve as engaging jawsfor the suture line. Alternatively, without departing from the spirit ofthis fourth embodiment, one of the pawls 941 or 942, preferablyanvil-like pawl 941 may be rigidly fixed relative to the fitting 943 andthereby act as a rigid engagement surface for cooperation withwedge-like pawl 942 which is rotatingly engaged to fitting 943 aspreviously described.

FIGS. 7A-7B illustrate a reusable anchoring mechanism 94, integral withsternum retractor 1. Alternatively, a disposable anchoring mechanism 94assembly may be designed and mechanically attached to a reusable sternumretractor 1 and replaced after every surgical intervention.Alternatively, if a disposable sternum retractor 1 is designed, themembers comprising anchoring mechanism 94 may also be disposable andfabricated in single-use plastic or polymeric materials, for instance.

An alternate design and configuration for incorporating anchoringmechanism 94 with sternum retractor 1 consists of embedding saidanchoring mechanism within arcuate arm 3 (or 4) below the surfacesdefining arcuate passage 71, and deepening slit-like channel 72accordingly. As a result, the positioning and articulation mechanismpreviously described may be inserted in arcuate passage 71, positionedalong arcuate passage 71, and engaged with arcuate rail 70 even in aposition over the location of embedded anchoring mechanism 94, withoutany resulting obstruction to said positioning and articulation mechanismfrom a suture line secured relative to anchoring mechanism 94.

FIGS. 8A-8B illustrate a fifth embodiment according to the presentinvention, one that allows the possibility of adjusting the magnitude ofthe clamping load on suture line 23. Internal body tissue IBT retractionwill be effectuated with a traditional suture 13, comprised of a curvedsuture needle 20 and a suture line 23, that becomes engaged withanchoring mechanism 95 disposed on sternum retractor 1, in a pluralityof locations similar to the disposition of anchoring ports 90 of thefirst embodiment. FIG. 8A illustrates only the most remote portionrelative to rack bar 5 of retractor spreader arm 3, with one anchoringmechanism 95 disposed laterally outward on said arm 3.

Anchoring mechanism 95 is comprised of a fitting 951, a profiled washer953, a helical spring 954, and a screw 952. Fitting 951 may be either anintegral extension of retractor arm 3 (or 4) or may be mechanicallyfastened to said retractor arm to form a rigid assembly during at leastthe duration of the surgical intervention requiring tissue retraction.Fitting 951 is preferably disposed below the depth of slit-like channel72. Screw 952 is comprised of a knob 958, a shoulder 957, and a threadedshaft 962. Helical spring 954 is first inserted over threaded shaft 962,placed in contact with the shoulder 957 of screw 952, said shoulderhaving a diameter greater than diameter of helical spring 954, andpreferably a groove on face of said shoulder to house first winding ofsaid helical spring. Profiled washer 953 is next inserted over threadedshaft 962. Screw 952 is then engaged with fitting 951, by virtue ofthreaded shaft 962 inserted into fitting threaded hole (not shown), inorder to configure the mechanical assembly of components defining theanchoring mechanism 95. The fitting threaded hole is preferably athrough hole, such that screw 952 may be threaded sufficiently intothreaded fitting hole to extend below fitting 951. The exposed portionof threaded shaft 962 may, at this point, be: (i) mechanically flaredoutwards, or (ii) engaged with a transverse retention pin fitted througha hole in said threaded shaft, or (iii) engaged with a circular clipfitted into an annular groove in said threaded shaft, or (iv) engagedwith a nut threaded member threaded on extreme-most portion of saidthreaded shaft, or (v) be engaged with other similar mechanical memberpreventing said threaded shaft from being withdraw from said fittingthreaded hole without first disengaging mechanical member. This preventsinadvertent disassembly of the anchoring mechanism 95 during thesurgical intervention, that may result by sufficiently unthreading anddisengaging threaded shaft 962 from fitting threaded hole. Profiledwasher 953 is designed with both its outer perimeter 955 and innerperimeter 956 bent significantly away from bottom face 960 of profiledwasher 953 to create firstly, a socket 964 on the top face of profiledwasher 953 to locate helical spring 954 and secondly, a beveled outsideedge between outer perimeter 955 and bottom face 960 of said profiledwasher serving as a guide to facilitate the insertion of suture line 23between said bottom face 960 and top face 959 of fitting 951.

When anchoring mechanism 95 is mechanically assembled, the helicalspring 954 is axially trapped between shoulder 957 of screw 952 andsocket 964 of profiled washer 953, but also free to rotate about itscenterline. Helical spring 954 is also free to rotate relative to screw952 and free to rotate relative to washer 953. Turning knob 958 of screw952 such that it decreases the distance between shoulder 957 and fittingface 959 will increase the mechanical force that helical spring 954applies on profiled washer 953. Conversely, if knob 958 is unscrewedsufficiently, the increase in distance between shoulder 957 and fittingface 959 will unload the helical spring 954 entirely, and rendering theinsertion of the portion of suture line 23 between face 960 of profiledwasher 953 and face 959 of fitting 951. To increase the clamping load onthe portion of suture line 23 between said faces 959 and 960, knob 958is turned until the load applied by the helical spring 954 on profiledwasher 953 is sufficiently great to prevent suture line 23 from slippingout between said faces 959 and 960 given a specific internal body tissueIBT retraction load.

In broad terms, the method of deployment for this fifth embodimentaccording to the present invention, consists of:

a) piercing the internal body tissue IBT with needle 20 and threading alength AC of suture line 23 through said internal body tissue IBT;

b) simultaneously inserting both lengths AC and DF of suture line 23firstly in slit-like channel 72 and secondly in between bottom face 960of profiled washer 953 and face 959 of fitting 951;

c) grasping both lengths AC and DF of suture line 23, in the vicinity ofpoint A and point F thereof, and retracting pierced internal body tissueIBT by pulling simultaneously both said lengths longitudinally outwardthrough slit-like channel 72 and through in between face 960 and face959, sufficiently to obtain the desired internal body tissue IBTretraction or displacement;

d) screwing knob 958 sufficiently such that the clamping load onprofiled washer 953, and consequently on the suture line 23 at point Band point E, is sufficient to react the required retraction load fordesired internal body tissue IBT retraction or displacement;

e) simultaneously releasing both lengths AC and DF of suture line 23,profiled washer 953 being in contact with the suture line 23 at point Band point E of said suture line;

f) if required, readjusting the magnitude of internal body tissue IBTretraction or displacement, by simultaneously grasping suture line 23between lengths AB and EF, unscrewing knob 958 and pullingsimultaneously both said lengths in manner described in step (c) above;

g) if required, readjusting the direction of retraction load applied tothe internal body tissue IBT or readjusting the direction ofdisplacement exerted on the internal body tissue IBT by disengagingsuture line 23 from existing anchoring mechanism 95, and re-engagingsuture line 23 in another anchoring mechanism 95 disposed in analternate location on sternum retractor 1, by repeating steps (c) to (e)described above.

This fifth embodiment offers advantages in that the clamping load ontraditional suture 13 may be tailored to a specific surgicalintervention, or to the specific internal body tissue that will beretracted or displaced. For example, if the risk of applying anexceedingly high load during a surgical intervention on the retractedinternal body tissue IBT will result in unwanted tearing of body tissue,the maximum clamping load that can be exerted on the suture line 23 maybe set to a prescribed value by turning knob 958 a specific amount thatwill preload helical spring 954 such that surgical loads applied to theinternal body tissue IBT higher than this prescribed value will resultin the suture line 23 being released from anchoring mechanism 95, ratherthan resulting in unwanted tearing of body tissue or unwanted tissuetrauma. In this manner, the components of the anchoring mechanism 95cooperate to provide a failsafe feature.

FIG. 8B illustrates suture line 23 inserted in anchoring mechanism 95,during step (b) of the method of deployment described above, with screw952 sufficiently unscrewed to relieve profiled washer 953 and portion ofsuture line 23 inserted in anchoring mechanism 95 free of any clampingload from helical spring 954.

If it is desired to ensure that profiled washer 953 will not rotaterelative to screw 952 when turning knob 958, a guide pin (not shown) maybe inserted into top face 959 of fitting 951, said pin standingsufficiently proud above said surface 959 that it is capable of engaginga hole, eccentrically located relative to the centerline of profiledwasher 953, thereby fixing the angular rotational position of profiledwasher 953 relative to fitting 951.

Alternatively, this fifth embodiment may be modified to provide clampingof a portion of suture line 23 without the failsafe feature describedabove, and without a controllable application of clamping load on saidportion of suture line. Spring 954 and profiled washer 953 may beeliminated and the portion of suture line 23 clamped between shoulder957 of screw 952 and face 959 of fitting 951. As a result, only twosubstantially discrete clamping load settings are obtained, either zeroclamping or fully-engaged-thread clamping load for a specific thread 962size. Alternatively, other variants to this fifth embodiment arepossible such as those which may incorporate a Belleville washer, wavespring, helical spring washer, or other like washers, known in the fieldof mechanical design and available in a variety of sizes and shapes.

FIGS. 9A-9B illustrate a sixth embodiment according to the presentinvention, one that tends to be energized by the very tension it isintended to react in suture line of tissue retractor. Internal bodytissue IBT retraction will be effectuated with a traditional suture 13,comprised of a curved suture needle 20 and a suture line 23, thatbecomes engaged with anchoring mechanism 97 disposed on sternumretractor 1, in a plurality of locations similar to the disposition ofanchoring ports 90 of the first embodiment. FIG. 9A illustrates only themost remote portion relative to rack bar 5 of retractor spreader arm 3,with one anchoring mechanism 97 disposed laterally outward on said arm3.

Anchoring mechanism 97 is comprised of a fitting 971, a carriage 972, aswing plate 977, a pinch arm 974, and an energizing arm 975. Fitting 971may be either an integral extension of retractor arm 3 (or 4) or may bemechanically fastened to said retractor arm to form a rigid assemblyduring at least the duration of the surgical intervention requiringtissue retraction.

Swing plate 977 is rotatingly engaged with carriage 972 by pivot pin973, which is firstly slidingly inserted through a cylindrical bore (notshown) in carriage 972, and secondly rigidly engaged into an opening onswing plate 977, by a variety of ways similar to the rigid engagement ofpins in previously described embodiments. Swing plate 977 is free torotate about the centerline axis of pivot pin 973, which axially retainssaid swing plate 977 relative to carriage 972. Swing plate 977 iscomprised of two substantially cylindrical cantilevered shafts, a pincharm 974 and an energizing arm 975, both of which are preferably rigidlyattached to swing plate 977, and both of which have their longitudinalaxes preferably perpendicular to plate 977. Pinch arm 974 is positionedon plate 977 such that substantially cylindrical surface 979 of pincharm 974 opposes carriage surface 980 when said swing plate 977 rotatesto clamp across a portion of suture line 23 inserted and engaged betweensaid surfaces 979 and 980. The axis of pivot pin 973, longitudinal axisof pinch arm 974, the longitudinal axis of energizing arm 975, and thelongitudinal axis of carriage surface 980 are all parallel to eachother.

In broad terms, the method of deployment for this sixth embodimentaccording to the present invention, consists of:

a) piercing the internal body tissue IBT with needle 20 and threading alength AC of suture line 23 through said internal body tissue IBT;

b) simultaneously inserting both lengths AC and DF of suture line 23between energizing arm 975 and pinch arm 974 by winding said bothlengths firstly around the energizing arm 975 and secondly around thepinch arm 974 as illustrated in FIG. 7A;

c) grasping both lengths AC and DF of suture line 23, in the vicinity ofpoint A and point F, and retracting pierced internal body tissue IBT bypulling simultaneously both said lengths longitudinally outward throughanchoring mechanism 97 (in direction perpendicular to axis of pivot pin973), sufficiently to obtain the desired internal body tissue IBTretraction or displacement;

d) simultaneously releasing both lengths AC and DF of suture line 23,resulting in point B and point E of said suture line being engagedbetween cylindrical surface 979 and carriage surface 980;

e) if required, readjusting the magnitude of internal body tissue IBTretraction or displacement, by simultaneously grasping both lengths ABand EF of suture line 23, and pulling simultaneously both said lengthsin manner described in step (d) above;

f) if required, readjusting the direction of retraction load applied tointernal body tissue IBT or readjusting the direction of displacementexerted on the internal body tissue IBT by disengaging suture line 23from existing anchoring mechanism 97, and re-engaging suture line 23 inanother anchoring mechanism 97 disposed in an alternate location onsternum retractor 1, by repeating steps (c) to (e) described above.

When a tension load is applied to suture line 23 at point C and D, andwhen said suture line is in tension and deflected around energizing arm975 as illustrated in FIG. 7A, the normal force between cylindricalsurface 979 and carriage surface 980 is amplified relative to both thetension acting on suture line 23 and the closing force acting onenergizing arm 975, by virtue of the leverage effect imparted by swingplate 977. The distance between longitudinal axis of pinch arm 974 tothe centerline of pivot pin 973 is inferior to the distance betweenlongitudinal axis of energizing arm 975 to the centerline of pivot pin973, preferably by 30 to 70 percent, such that the resultant clampingforce generated by the amplified normal force between cylindricalsurface 979, carriage surface 980, and the portion of suture line 23engaged therebetween will always be greater than the tension applied insuture line 23 at point C and D. The said resultant clamping force beinggreater than the said tension results in the suture line 23 beingsecured relative to anchoring mechanism 97.

Tension applied to suture line 23 at point A and point F opposes andreduces the resultant clamping force on suture line 23 at point B andpoint E engaged between cylindrical surface 979 and carriage surface980. Tension applied to suture line 23 at point A and point F can beapplied to such an extent as to completely overcome the said resultantclamping force, thus allowing suture line 23 to be pulled, as desired,to slide through the cooperating surfaces 979 and 980 of anchoringmechanism 97 in the direction of application of said tension. Guide knob987 on pinch arm 974 and guide knob 988 on energizing arm 975 serve todiscourage disengagement of suture line 23 from said arms 974 and 975should there be any significant misalignment between either of length ACor length DF of suture line 23 and a plane perpendicular to thelongitudinal axes of arms 974 and 975.

FIG. 9A-9B illustrates this sixth embodiment according to the presentinvention with the engaged suture line 23 extending above both thearcuate rail 70 and arcuate passage 71. Alternatively, similar to theprevious embodiments, the fitting 971 and carriage 972 may be configuredat a lower depth on sternum retractor 1, and slit-like passages 72included in arcuate arm 3 such that the engaged suture line 23 will restat the maximum depth of slit-like channel 72 thereby providing anunobstructed access to arcuate passage 71 for the positioning andarticulation mechanism described above.

The embodiments of the present invention may be used in beating heartcoronary artery bypass graft (CABG) surgery to position and orient thebeating heart within the retracted chest cavity of the patient byapplying a tissue retraction load to the pericardium tissue. Thepericardium tissue is typically incised to expose at least a portion ofthe heart surface where the bypass graft will be performed, but remainsanatomically attached to the beating heart. For example, the pericardiumtissue may be engaged by a number of tissue retractors secured to eitheranchoring ports or anchoring mechanisms, according to the presentinvention, in order to place the longitudinal axis of the of beatingheart in a substantially vertical orientation to facilitate grafting ofthe posterior arteries. A number of tissue retractors comprising acurved needle 20 and a suture line 23 may pierce the pericardium tissueclose to the base of the heart (or close to the pericardial reflection):one tissue retractor placed between the superior and inferior pulmonaryvein, a second tissue retractor below the inferior pulmonary vein, athird one midway between the apex of the heart and the inferiorpulmonary vein, and a fourth one towards the diaphragmatic face near theinferior vena cava. Retraction loads are subsequently applied to thesetissue retractors, and said tissue retractors each secured to ananchoring mechanism disposed on sternum retractor 1 thereby maintainingthe desired tissue retraction, in one of the manners described above,according to the present invention.

The above descriptions of the preferred embodiments should not beinterpreted in any limiting manner since variations and refinements arepossible without departing from the spirit of the invention. Forexample, the tissue-piercing needle 20 may be either solid throughout orof a hollow cross-section, the curvature of the needle may be of anynumber of variants from almost straight to slightly curved to curved,cross section can be circular or elliptical or have a local flat spot,along the curved length of the needle, to improve the stability of theclamped needle within the mating jaws of a surgical clamp used whilepiercing tissue or some other manipulation with the tissue retractor.The wire-like filament 23 may be of various lengths, diameters,material, braided or multi-stranded fabrication, or even made from asilastic material. As well, the suture contacting surfaces of thecomponents of the anchoring mechanism which cooperate to clamp, pinch,or retain the portion of suture line 23 may be textured or otherwisetreated to tend to improve the friction between said suture line andsaid suture contacting surfaces.

1. A surgical device, comprising: a surgical retractor having first andsecond oppositely disposed retractor portions operatively coupled byconnecting structure and defining a space therebetween through which asurgical site is accessed; a suture retention device on said surgicalretractor and adapted for retaining a surgical suture relative to saidsurgical retractor during a surgical intervention, said suture retentiondevice comprising: a first member having a first suture contact surface;and a second member having a second suture contact surface, said secondmember being rotatable relative to said first member; said first memberand second member configured and sized to create a retention slottherebetween for receiving a portion of the surgical suture; and asuture guide channel on said surgical retractor and positioned betweensaid retention slot and said space, whereby said suture guide channel isadapted to direct the suture from the surgical site to said retentionslot between said first and second members; wherein said first andsecond suture contact surfaces cooperate to frictionally retain thesurgical suture relative to said surgical retractor when said sutureportion is placed within said retention slot and said second memberrotates relative to said first member to bring said first and secondcontact surfaces into contact with the suture portion.
 2. The surgicaldevice as recited in claim 1, wherein said first member furthercomprises a pinch roller and said second member further comprises atraction roller, and said suture retention device further comprising atraction surface; wherein said traction roller is adapted to roll alongsaid traction surface between a suture-releasing configuration in whichsaid first and second suture contact surfaces are in a substantiallyspaced relationship relative to each other to allow lengthwise movementof the suture portion and a suture-retaining configuration in which saidfirst and second suture contact surfaces are in substantially proximaterelationship relative to each other to prevent lengthwise movement ofthe suture portion.
 3. The surgical device as recited in claim 2 whereinsaid pinch roller is cylindrical and has a center axis, said pinchroller further being rotatable about said center axis.
 4. The surgicaldevice as recited in claim 3 wherein said pinch roller and tractionroller are configured, sized and positioned so as to frictionally retainthe suture portion in said suture-retaining configuration by exerting aclamping force on the suture portion, said clamping force increasingwhen a tension is applied to the surgical suture in at least onedirection.
 5. The surgical device as recited in claim 4 wherein saidtraction roller is configured to be maintained in rolling contact withsaid traction surface as said traction roller moves between saidsuture-releasing configuration and said suture-retaining configuration.6. The surgical device as recited in claim 5 wherein said tractionroller is configured to move towards said suture-retaining configurationas said surgical suture is moved longitudinally through said retentionslot along said at least one direction, thereby frictionally entrainingsaid traction roller to roll against said traction surface towards saidpinch roller.
 7. The surgical device as recited in claim 5 wherein saidtraction roller moves towards said suture-releasing configuration assaid surgical suture is moved longitudinally through said retention slotin a direction opposite to said at least one direction, therebyfrictionally entraining said traction roller to roll against saidtraction surface away from said pinch roller.
 8. The surgical device asrecited in claim 5 wherein at least one of said first or second suturecontact surfaces includes a friction-enhancing configuration forincreasing friction exerted on the suture portion when said first andsecond suture contact surfaces are in said suture-retainingconfiguration and the surgical suture is inserted therebetween.
 9. Thesurgical device as recited in claim 8 wherein said second suture contactsurface of said traction roller is provided with said friction-enhancingconfiguration, said friction enhancing surface including a series ofridges that mesh with corresponding grooves in said traction surface toenhance rolling of said traction roller against said traction surface.10. The surgical device as recited in claim 3 wherein said sutureretention device is removably coupled to said surgical retractor. 11.The surgical device as recited in claim 1, further comprising attachmentstructure on at least one of said first or second retractor portions andadapted to retain surgical instruments for use with said surgicalretractor, wherein said suture guide channel extends through saidattachment structure.
 12. The surgical device as recited in claim 11,wherein: said attachment structure comprises an attachment slot definedby a pair of opposing sidewalls and a bottom wall extending between saidsidewalls, and; said suture guide channel extends to a depth below saidbottom wall of said slot to allow insertion of the suture into thesuture guide channel without interfering with surgical instrumentsretained on said at least one first or second retractor portions. 13.The surgical device as recited in claim 1 wherein said suture retentiondevice is integrally formed on said surgical retractor.
 14. The surgicaldevice as recited in claim 1 wherein said suture retention device isremovably coupled to said surgical retractor.
 15. A surgical device,comprising: a surgical retractor having first and second oppositelydisposed retractor portions operatively coupled by connecting structureand defining a space therebetween through which a surgical site isaccessed; at least one of said retractor portions including a sutureguide channel configured to receive a segment of a surgical suture; anda suture retention device capable of retaining the surgical suturerelative to said surgical retractor during a surgical intervention, saidsuture retention device positioned on said surgical retractor andcomprising: a traction surface; a first member having a first suturecontact surface; and a second member having a second suture contactsurface, said second member adapted to roll against said tractionsurface and movable relative to said first member; and said first memberand second member configured and sized to create a retention slottherebetween for receiving a portion of the surgical suture; whereinsaid retention slot is substantially in registration and communicationwith said suture guide channel.
 16. The surgical device as recited inclaim 15 wherein said surgical retractor includes an instrument-mountingrail configured for mounting a surgical instrument used during thesurgical intervention and, in use, the instrument is operativelypositionable with respect to said instrument-mounting rail withoutinterference to the surgical suture while the suture portion is receivedwithin said retention slot.
 17. A surgical device, comprising: asurgical retractor having first and second oppositely disposed retractorportions operatively coupled by connecting structure and defining aspace therebetween through which a surgical site is accessed, saidsurgical retractor including an instrument-mounting rail configured formounting a surgical instrument for use during the surgical intervention,said instrument-mounting rail including a suture guide channel formedtherein for receiving a segment of a surgical suture; and a sutureretention device for retaining the surgical suture relative to saidsurgical retractor during a surgical intervention, said suture retentiondevice positioned on said surgical retractor and comprising: a tractionsurface; a first member, said first member having a first suture contactsurface; and a second member, said second member having a second suturecontact surface, said second member adapted to roll against saidtraction surface and being movable relative to said first member; saidfirst member and said second member configured and sized to create aretention slot therebetween for receiving a portion of the surgicalsuture; wherein said retention slot in said suture retention device isin communication with said suture guide channel so as to allow insertionof the surgical suture into said suture guide channel and into saidretention slot without interfering with the operation of saidinstrument-mounting rail.
 18. A surgical device, comprising: a surgicalretractor including first and second oppositely disposed retractorportions operatively coupled by connecting structure and defining aspace therebetween through which a surgical site is accessed; retentiondevice support structure on said surgical retractor; a traction surfaceon said retention device support structure; a first member operativelycoupled to said retention device support structure and having a firstsuture contact surface; a second member operatively coupled to saidretention device support structure and having a second suture contactsurface, said second member being movable relative to said first memberby rolling along said traction surface and cooperating with said firstmember to define a retention slot therebetween for receiving a portionof a surgical suture; and a suture guide channel disposed between saidretention slot and said space between said first and second retractorportions, whereby said suture guide channel is adapted to direct thesurgical suture from the surgical site to said retention slot betweensaid first and second members.
 19. The surgical device as recited inclaim 18, wherein said retention device support structure is disposed onone of said first or second retractor portions.
 20. The surgical deviceas recited in claim 18, wherein said retention device support structureis integrally formed with said surgical retractor.
 21. The surgicaldevice as recited in claim 18, wherein said retention device supportstructure is removably coupled with said surgical retractor.